AIDS

Definition

Acquired immunodeficiency syndrome (AIDS) is an advanced form of HIV infection in which the patient has developed opportunistic infections or certain types of cancer and/or the CD4+ T cell count has dropped below 200 per microliter (200/?L). Human immunodeficiency virus (HIV) is a retrovirus—a type of virus that uses an enzyme called reverse transcriptase to enable it to become part of its host's DNA and replicate. As of 2008 there is no cure for AIDS and no vaccine against the infection.

Description

Background

HIV infection is thought to have emerged as a human disease in sub-Saharan Africa at some point in the mid-twentieth century, most likely when the virus made a species jump from chimpanzees into humans. The first cases of AIDS in the United States were reported in 1981 in a group of homosexual men in New York City. In the following years other cases of HIV transmission through blood transfusions were reported, followed by reports of children developing AIDS via transmission of the virus from an infected mother to her infant during childbirth. It is now known that HIV can be transmitted through direct contact of a mucous membrane or the bloodstream with a body fluid contaminated by the virus. Body fluids include breast milk, semen, and vaginal secretions as well as blood and saliva. Transmission can occur through oral, anal, or vaginal intercourse; blood transfusion; the use of contaminated hypodermic needles; breastfeeding; and needlestick injuries.

Stages

As of the early 2000s, HIV infection is usually described as progressing in three stages:

• Primary HIV infection/acute retroviral syndrome (ARS). Some patients have no symptoms at this stage; however, about 30 percent develop acute retroviral syndrome (ARS) a few days or weeks after exposure. ARS is often mistaken for flu, strep throat, mononucleosis, or even secondary syphilis. The patient may or may not have developed antibodies to HIV (a process known as seroconversion) at this point; thus a test for HIV infection in this early period may not yield positive results even though the patient is in fact infected. In this stage the CD4 cell count is 500/?L or higher.
• Clinically asymptomatic stage. The acute symptoms (if any) of the primary infection stage go away. The virus continues to replicate in the body for as long as 10 years, however, destroying the structures of the patient's lymph nodes and gradually depleting the CD4+ T cells that fight the infection. The CD4+ T cell count in this stage is between 500 and 200 cells per microliter.
• Symptomatic stage (full-blown AIDS). In this third stage, the body's immune system begins to fail. The usual measurement for this stage is a CD4+ T cell count that drops below 200/?L. At this point the patient develops repeated opportunistic infections and may develop AIDS-related cancers.

As of the early 2000s, it takes an average of 11 years in younger adults for HIV infection to progress to AIDS; in seniors, the disease usually progresses faster.

Demographics

AIDS is considered the most destructive pandemic of the past century. As of 2008, the disease is estimated to have killed 25 million people around the world since it was first identified in 1981. An estimated 33.2 million people worldwide are presently living with the disease. According to the Centers for Disease Control and Prevention (CDC), an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS at the end of 2003, with 24–27 percent undiagnosed and unaware that they are infected. Seniors are more likely than younger patients to be undiagnosed, with diagnostic evaluations in seniors often being delayed for as long as 10 months after the first symptoms of infection.

The demographics of HIV infection among the elderly have changed since the early days of the AIDS epidemic. In the mid-1980s, most cases of AIDS among seniors in the United States were the result of transfusions with contaminated blood. The introduction of effective screening tests for blood products has virtually eliminated this path of HIV transmission, however; as of 2008, almost all cases of AIDS in seniors are the result of sexual activity. In the United States, about 10 percent of all cases of AIDS occur in people over 50, and 3 percent in people over 60. About 35 percent of seniors who develop AIDS are homosexual or bisexual men; others are heterosexual men living in urban areas who engage in high-risk sex with prostitutes.

One reason that sexually active seniors are particularly at risk for HIV infection is that they are rarely concerned about contraception. Adults over 50 are five times more likely than younger people to have unprotected sex because they think of condoms as a method of birth control rather than a means of preventing disease transmission. In addition, older women have thinner and more fragile tissues lining the walls of the vagina; these tissues are more likely to be bruised or damaged during unprotected intercourse, making it easier for the virus to enter the underlying tissues. Several studies done in 2006 and 2007 have reported that older women are less likely than their younger counterparts to take precautions against HIV infection, in part because they are less sexually active than older men, and partly because they do not perceive themselves as being at risk for HIV infection.

According to the Merck Manual of Geriatrics, “Practically no prevention information on AIDS is targeted at elderly persons, although most elderly persons are sexually active.” According to statistics compiled by the Centers for Disease Control and Prevention, about 2100 men between the ages of 55 and 59 are diagnosed with HIV infection each year, and 800 over the age of 65. Since the epidemic began in 1981, 15,000 seniors over age 65 have been diagnosed with HIV in the United States.

Causes and symptoms

Causes

AIDS is caused by a retrovirus that contains an enzyme called reverse transcriptase. Reverse transcriptase converts viral RNA into a proviral DNA copy that becomes integrated into the DNA of the host cell. As the virus infects more cells, it gradually reduced the number of CD4+ T helper cells in the blood. These cells are the body's infection fighters. Counting the number of CD4+ T cells in a blood sample is one way to monitor the disease progress in someone infected with HIV.

Risk factors

Some seniors are at higher risk than others of HIV infection. In order to determine whether HIV testing should be a personal priority, the senior should use the following checklist of high-risk behaviors (for 1978 and later):

• Shared needles for injecting drugs or steroids.
• If a male, had unprotected sex with other males.
• Had unprotected sex with someone known or suspected to be infected with HIV.
• Had a blood transfusion between 1978 and 1985.
• Had another sexually transmitted disease.
• Had unprotected sex with anyone with any of the five previous risk factors.

Symptoms

The symptoms of HIV infection vary according to the progress of the infection. As mentioned above, about 30 percent of patients develop an acute syndrome resembling flu within a month of exposure to HIV. The patient typically has a fever, headache, swollen lymph nodes, and fatigue. The symptoms then disappear; however, the infected person is highly contagious in this early phase and can readily pass the virus on to others.

In the second phase, the virus may be silent, but more commonly it produces complications. Patients in this stage of infection may have the following symptoms:

• Swelling of the lymph nodes that lasts three months or longer.
• Fevers and night sweats.
• Loss of energy.
• Weight loss.
• Frequent yeast infections of the vagina or mouth and throat. Yeast infections of the mouth are sometimes called thrush.
• Skin rashes or flaky skin that does not go away.
• Short-term memory loss. This symptom helps to explain why HIV infection in seniors is often misdiagnosed as early-stage Alzheimer' s.

In full-blown AIDS, the person develops one or more of the following opportunistic infections. Death usually results from one of these infections or from an AIDS-related cancer.

• Lung infections: these include a type of pneumonia caused by an organism known as Pneumocystis jirovecii, a yeast-like fungus; and tuberculosis.
• Mouth infections: these include oral candidiasis, or thrush.
• Infections of the digestive tract: these include parasitic as well as bacterial infections, and are often marked by severe diarrhea.
• Infections of the central nervous system: these include meningitis and toxoplasmosis. AIDS dementia complex (ADC), which is often misdiagnosed as Alzheimer's disease, is caused by destruction of brain tissue by toxins secreted by HIV. AIDS dementia complex affects between 10 and 20 percent of AIDS patients in the United States and is often the first symptom of full-blown AIDS. Like Alzheimer's, ADC is characterized by memory loss, inability to concentrate, loss of motor ability, poor balance, and mood changes.

AIDS-related cancers include Kaposi's sarcoma, a skin cancer occasionally found in older men who do not have HIV infection; and cervical cancers in women. AIDS patients are also at increased risk of developing Hodgkin's disease, Burkitt's lymphoma, and cancers of the anus or rectum.

Diagnosis

Physical examination and history

The patient's history is often the most important single diagnostic clue to HIV infection, particularly if he or she admits to unsafe sexual practices or intravenous drug use. If the doctor suspects HIV infection on the basis of the flu-like symptoms of acute retroviral syndrome, or if the patient requests HIV testing, the doctor will usually order appropriate blood or oral fluid tests.

Laboratory tests

HIV infection is usually diagnosed by a blood test, either an enzyme-linked immunosorbent assay (ELISA) test or a rapid screening test, and confirmed by a second blood test known as a Western blot test. A newer method of testing involves the collection of oral fluid from the patient's gums and teeth on a swab, but its results must also be confirmed by a Western blot test. In most cases an infected person's blood will develop antibodies to HIV within 1 to 3 months of being infected; however, a blood test may not yield accurate results within this window period, as it is known. The doctor may ask the senior to come back for a second blood test if the results of the first are inconclusive.

The doctor may also order a complete blood count and a stool test (if the patient is suspected of having intestinal parasites). If the patient appears to have an opportunistic infection of the nervous system, the doctor may order a lumbar puncture in order to test a sample of spinal fluid. In some cases the doctor may take a sample of nerve or muscle tissue for a biopsy.

Imaging tests

The doctor may order a chest x-ray if opportunistic infections of the lung are suspected.

Treatment

Post-exposure prophylaxis (PEP) Post-exposure prophylaxis (PEP) is a four- to eight-week course of antiretroviral drugs given to persons immediately after exposure (through rape, unprotected sex, or needlestick injuries) to HIV to prevent them from being infected by the virus. To be effective, PEP must be started within 48 hours of exposure. It has some unpleasant side effects, including severe nausea and headaches .

Antiretroviral therapy (ART)

Antiretroviral therapy (ART) refers to drugs or combinations of drugs given to AIDS patients to slow down the replication of HIV and to prevent it from developing resistance to treatment. The drugs are grouped into several categories according to the stage of the virus's life cycle that they inhibit. Some inhibit reverse transcription, others prevent the virus's DNA from being integrated into the DNA of the infected host cell, and still others prevent HIV from gaining entrance into its target cell.

In 1996, a new approach to ART known as highly active antiretroviral therapy or HAART was introduced. HAART is not one drug but a combination of various antiretroviral agents given to patients to prevent the virus from replicating and to discourage mutations of the virus. The drugs must be taken in combination because no medication by itself is able to suppress HIV for very long. One early problem with HAART was the complicated dosing schedules of the different drugs prescribed for an individual patient. To encourage adherence to treatment schedules (which must be at least 98 percent complete to protect the patient from developing a strain of the virus resistant to HAART), some pharmaceutical companies developed fixed-dose combinations—medications in which several antiretroviral drugs that are known to work well together are combined in a single pill.

Guidelines for offering HAART treatment to patients were published in the late 1990s because the drugs have so many adverse effects (including hair loss, muscle cramps and pains, kidney or liver failure, insomnia , inflammation of the pancreas, dizziness and mental confusion, headache, nausea and vomiting, and numbness in hands or feet) that many patients were not compliant with dosage schedules and developed drug-resistant mutations of the HIV virus. Recommendations for HAART have been revised several times by the U.S. Department of Health and Human Services. The following is the most recent set of standards, issued in October 2005:

• All patients with history of an AIDS-defining illness or severe symptoms of HIV infection should receive antiretroviral therapy regardless of CD4+ T cell count.
• Antiretroviral treatment is recommended for asymptomatic patients with less than 200 CD4+ T cells/µL.
• Asymptomatic patients with CD4+ T cell counts of 201–350 cells/µL should be offered antiretroviral treatment.
• For asymptomatic patients with CD4+ T cell of greater than 350 cells/µL and plasma HIV RNA greater than 100,000 copies/ml, most experienced
• clinicians defer therapy but some clinicians may consider initiating antiretroviral treatment.
• Antiretroviral therapy should be deferred for patients with CD4+ T cell counts of greater than 350 cells/µL and plasma HIV RNA less than 100,000 copies/ml.

Doctors who specialize in treating AIDS in seniors maintain that HAART should be started as early as possible and as aggressively as possible in older adults because they respond more slowly to treatment. As of 2008, however, relatively little is known about the most effective drug combinations for seniors. There are no official guidelines for antiretroviral treatment in the elderly, and seniors are rarely included in clinical trials of new AIDS drugs. In addition, the negative side effects of antiretroviral drugs are more pronounced in seniors, and interactions with drugs that the senior is taking for other conditions are common complications of treatment for AIDS.

Complementary and alternative (CAM) treatments

CAM treatments that have been recommended for AIDS patients include multivitamin therapy, acupuncture, yoga, massage therapy , and the use of relaxation techniques to improve mood and relieve depression . Some studies indicate that naturopathic treatments slow the progression of HIV infection even though they cannot cure it. Interestingly, a study published in 2007 reported that seniors with AIDS are just as likely to use complementary therapies since the introduction of HAART as they were before 1996. The study also reported that men who used CAM were more likely to be college-educated, to have contracted HIV through intravenous drug use rather than through sex with other men, and to be African American rather than Caucasian.

NCCAM announced plans in 2007 to conduct a three-year study of CAM therapies used by adults diagnosed with HIV. According to the center, between 47 and 74 percent of HIV-positive persons in the United States have used some type of CAM approach—most often to relieve the side effects of HAART as well as to improve overall well-being. The study is scheduled to run from 2009 through 2011.

Nutrition/Dietetic concerns

AIDS symptoms related to nutrition

Seniors with AIDS frequently develop symptoms that affect digestion and nutrition as a result of the disease itself combined with the side effects of antiretroviral drugs. One common side effect is nausea and vomiting, which makes the patient more susceptible to opportunistic infections as well as rapid weight loss . A second common development is lipodystrophy. Lipodystrophy is the medical term for the redistribution of body fat that sometimes occurs in patients with HIV infection as a result of HAART, genetic factors, the length of time a person has been HIV-positive, and the severity of the disease. It is not completely understood as of the early 2000s why antiretroviral drugs and other factors have this effect.

The patient may notice new deposits of fat at the back of the neck (sometimes called “buffalo humps”) and around the abdomen. Conversely, fat may be lost under the skin of the face, resulting in sunken cheeks, or lost under the skin of the buttocks, arms, or legs. Lipodystrophy is not necessarily associated with weight loss.

Still another nutritional symptom of AIDS is wasting. Wasting refers to rapid unintentional weight loss (usually defined as 5 percent of body weight over a period of 6 months) combined with changes in the composition of the senior's body tissue. Specifically, the patient is losing lean muscle tissue and replacing it with fat. The patient's outward appearance may not be a reliable guide to wasting, particularly if he or she also has lipodystrophy. Weight loss associated with wasting may result from nausea and vomiting related to opportunistic infections of the digestive tract as well as from reactions to medication.

Food safety issues

Food safety is an critical concern for seniors with HIV infection because their immune systems have difficulty fighting off food- or water-borne disease organisms. While most people can get food poisoning or parasitic infections of the digestive tract if they drink contaminated water or do not prepare food properly, older adults with HIV infection can get severely ill as a result of these diseases. Food-borne illnesses are also much more difficult to treat in persons with AIDS or HIV infection, and may lead to malabsorption syndrome, a condition in which the body cannot absorb and make use of needed nutrients in food. Basic dietary safeguards include the following:

• Wash hands repeatedly in warm soapy water before and after preparing or eating food. Instant hand sanitizers should be used when away from home.
• Cook all meats, fish, and poultry to the well-done stage; do not eat sushi, raw oysters, or raw meat in any form.
• Do not use unpasteurized milk or dairy products.
• Do not eat raw, soft-boiled, or “wet” scrambled eggs, or Caesar salad made with raw egg in the dressing. Hard-boiled or hard-scrambled eggs are safe.
• Rinse all fruits and vegetables carefully in clean, safe water, and clean all cutting boards and knives that touch chicken and meat with soap and hot water before using these utensils with other food items.
• Keep all refrigerated foods below 40°F; check expiration dates on food packaging.
• Completely reheat leftovers before eating, and do not eat leftovers that have been stored in the refrigerator for longer than 3 days.
• Do not drink water that comes directly from lakes, streams, rivers, or springs, and ask for drinks without ice in restaurants.

Treatments for wasting syndrome include increasing the senior's daily calorie intake and the use of appetite stimulants. In general, multivitamins, other dietary supplements, or herbal teas prepared by reliable manufacturers and approved by the patient's physician are useful complementary treatments for seniors with AIDS. According to NCCAM, high doses of vitamins are one of the most frequently used CAM treatments for counteracting the side effects of antiretroviral drugs.

Therapy

Therapy for AIDS consists of combination drug treatment (HAART in most cases), along with nutritional counseling, treatment of opportunistic infections, skin cancer, and dementia as they arise. Treatment also includes counseling regarding safe sex practices and supportive psychotherapy for the emotional depression that frequently affects seniors with AIDS.

Seniors with AIDS-related dementia usually re-quire placement in a long-term care facility; there is no effective treatment for this complication of AIDS.

Prognosis

Seniors generally have a worse prognosis than younger adults diagnosed with AIDS. The earlier stages of HIV infection progress more rapidly to AIDS in seniors, the initial CD4+ T cell counts are lower, and the survival period is shorter. Whereas 80 percent of younger adults survive for a year after being diagnosed with AIDS, only 40 percent of seniors survive that long.

QUESTIONS TO ASK YOUR DOCTOR

• How can I lower my risk of HIV infection?
• What are the side effects of HAART, and what can I do to minimize them?
• What will happen if I miss a dose of my medication?
• Is it safe to combine HAART with my other prescription drugs?
• What dietary changes would you recommend?

The reasons for the poorer prognosis in older adults are not fully understood as of 2008. Various explanations include delayed diagnosis due to the fact that the early symptoms of HIV infection are easily confused with those of other diseases commonly found in older persons; inadequate treatment; the high rate of other diseases and disorders in the elderly that can further weaken the immune system; a lower rate of compliance with treatment regimens; and age-related changes in the immune system itself. It is thought that the immune system in older adults is less efficient in replacing T helper cells and so is more easily overwhelmed by HIV infection.

Prevention

The most effective preventive measure for AIDS is sexual abstinence, followed by sex within a monogamous relationship. Other measures include avoidance of intravenous drug use and avoidance of direct contact with the body fluids of persons who are HIV-positive.

KEY TERMS

Acute retroviral syndrome (ARS) —A syndrome that develops in about 30 percent of HIV patients within a few weeks of infection. ARS is characterized by nausea, vomiting, fever, headache, general tiredness, and muscle cramps.

CD4+ T cell —A type of helper cell in the human immune system that is attacked and infected by HIV. CD4 is a protein on the surface of these T cells that is used by the HIV virus to gain entry into the cells.

Enzyme-linked immunosorbent assay (ELISA) —A biochemical test used in immunology to detect the presence of antibody or antigen in a sample of blood serum. ELISA was the first screening test commonly used to detect HIV infection.

Highly active antiretroviral therapy (HAART) —An approach to HIV infection that consists of a combination of three or four separate drugs to treat the infection. It is not a cure for HIV infection but acts to slow the replication of the virus and discourage new mutations. HAART has a number of side effects that complicate compliance in AIDS patients.

Lipodystrophy —The medical term for redistribution of body fat in response to HAART, insulin injections in diabetics, or rare hereditary disorders.

Post-exposure prophylaxis (PEP) —A course of antiretroviral drugs given to people immediately following exposure to HIV infection from rape, unprotected sex, needlestick injuries, or sharing needles.

Retrovirus —A single-stranded virus that replicates by reverse transcription to produce DNA copies that are incorporated into the genome of infected cells. AIDS is caused by a retrovirus.

Seroconversion —The development of detectable specific antibodies in a patient's blood serum as a result of infection or immunization.

T-lymphocyte —A type of white blood cell, also knownas a T-helper cell, a Th cell, aneffector Tcell, or a CD4+ T cell, whose numbers in a blood sample can be used to monitor the progression of HIV infection.

Western blot —A procedure that uses electrical current passed through a gel containing a sample of tissue extract in order to break down the proteins in the sample and detect the presence of antibodies for a specific disease. The Western blot method is used in HIV testing to confirm the results of an initial ELISA test.

Caregiver concerns

A caregiver for a senior with AIDS should be concerned with the following:

• Complete compliance with the senior's HAART regimen. Failure to take the medications exactly as directed can lead to resistant forms of HIV and eventual treatment failure. A handout for patients on how to take antiretroviral medications is available on the American Academy of Family Physicians website at http://www.aafp.org/afp/20030815/689ph.html.
• Nausea, vomiting, and weight loss, or signs of lipodystrophy or wasting syndrome. The doctor may recommend a consultation with a professional dietitian.
• Signs of dementia. As noted earlier, AIDS-related dementia in seniors is often misdiagnosed as Alzheimer's disease.
• Signs of drug interactions between the senior's antiretroviral therapy and medications he or she may be taking for other diseases.
• Signs of upper respiratory infections, particularly pneumonia or thrush.
• Skin disorders, including changes in the skin that may indicate cancer.

Resources

BOOKS

Beers, Mark H., M. D., and Thomas V. Jones, MD. Merck Manual of Geriatrics, 3rd ed., Chapter 134, “Human Immunodeficiency Virus Infection.” Whitehouse Station, NJ: Merck, 2005.

Klausner, Jeffrey D., and Edward W. Hook, III, eds. Current Diagnosis and Treatment of Sexually Transmitted Diseases. New York: McGraw-Hill Medical, 2007.

Lee, Sharon Dian. HIV and Aging. New York: Informa Healthcare USA, 2008.

Pelletier, Kenneth R., MD. The Best Alternative Medicine, Part II, “CAM Therapies for Specific Conditions: AIDS.” New York: Simon & Schuster, 2002.

PERIODICALS

Akers, A., L. Bernstein, S. Henderson, et al. “Factors Associated with Lack of Interest in HIV Testing in Older At-Risk Women.” Journal of Women's Health (Larchmont) 16 (July-August 2007): 842–858.

Branson, B. M. “State of the Art for Diagnosis of HIV Infection.” Clinical Infectious Diseases 45 (December 15, 2007): S221–225.

Josephs, J. S., J. A. Fleishman, P. Gaist, et al. “Use of Complementary and Alternative Medicines among a Multistate, Multisite Cohort of People Living with HIV/AIDS.” HIV Medicine 8 (July 2007): 200–305.

Lindau, S. T., L. P. Schumm, E. O. Laumann, et al. “A Study of Sexuality and Health among Older Adults in the United States.” New England Journal of Medicine 357 (August 23, 2007): 762–774.

Manfredi, Roberto, and Francesco Chiodo. “A Case-Control Study of Virological and Immunological Effects of Highly Active Antiretroviral Therapy in HIV-infected Patients with Advanced Age.” AIDS 14 (July 7, 2000): 1475–1477.

Perlmutter, Barbara L., Jordan B. Glaser, and Samwel O. Oyugi. “How to Recognize and Treat Acute HIV Syndrome.” American Family Physician 60 (August 1999): 535–546.

“Position of the American Dietetic Association and Dietitians of Canada: Nutrition Intervention in the Care of Persons with Human Immunodeficiency Virus Infection.” Journal of the American Dietetic Association 104 (September 2004): 1425–1441.

Tichy, A. M., and M. L. Talashek. “Older Women: Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome.” Nursing Clinics of North America 27 (December 1992): 937–949.

Weerasuriya, N., and J. Snape. “Oesophageal Candidiasis in Elderly Patients: Risk Factors, Prevention and Management.” Drugs and Aging 25 (February 2008):119–130.

OTHER

Centers for Disease Control and Prevention (CDC). Deciding If and When to Be Tested, posted January 22, 2007. http://www.cdc.gov/hiv/topics/testing/resources/qa/be_tested.htm [cited February 15, 2008].

Centers for Disease Control and Prevention (CDC). HIV Partner Counseling and Referral Services: Guidance. Washington, DC: U.S. Department of Health and Human Services, 1998.

Centers for Disease Control and Prevention (CDC). Voluntary HIV Counseling and Testing: Facts, Issues and Answers. Washington, DC: U.S. Department of Health and Human Services, 1998. Available online in PDF format at http://cdcnpin.org/brochures/Testing.pdf [cited February 16, 2008].

Chan-Tack, Kirk M. “Early Symptomatic HIV Infection.” eMedicine, February 20, 2007. http://www.emedicine.com/med/topic86.htm [cited March 9, 2008].

Dubin, Jeff. “HIV Infection and AIDS.” eMedicine, February 5, 2007. http://www.emedicine.com/emerg/topic253.htm [cited February 14, 2008].

U.S. Food and Drug Administration (FDA). Eating Defensively: Food Safety Advice for Persons with AIDS. Available online at http://www.cfsan.fda.gov/?dms/aidseat.html [updated 2005; cited March 9, 2008].

National Center for Complementary and Alternative Medicine (NCCAM). Project Concept Review: CAM Approaches in the Management of HIV Disease and Its Complications. Bethesda, MD: NCCAM, 2007. Available online at http://nccam.nih.gov/research/concepts/consider/hivncam.htm [cited March 9, 2008].

ORGANIZATIONS

American Academy of HIV Medicine, 1705 DeSales Street NW, Suite 700, Washington, DC, 20036, (202) 659-0699, (202) 659-0976, [email protected], http://www.aahivm.org/index.php?option=com_frontpage&Itemid=1.

Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, (404) 498-1515, (800) 311-3435, http://www.cdc.gov/.

Centers for Disease Control and Prevention National Prevention Information Network (CDC NPIN), P.O. Box 6003, Rockville, MD, 20849, (404) 679-3860, (800) 458-5231, (888) 282-7681, [email protected], http://www.cdcnpin.org/scripts/about/index.asp.

Food and Drug Administration (FDA), 5600 Fishers Lane, Rockville, MD, 20857, (888) 463-6332, http://www.fda.gov/default.htm.

HIV InSite, University of California San Francisco, Center for HIV Information, 4150 Clement Street, Box 111V, San Francisco, CA, 94121, (415) 379 5547, info@ hivinsite.ucsf.edu, http://hivinsite.ucsf.edu/InSite.

National Center for Complementary and Alternative Medicine (NCCAM), 9000 Rockville Pike, Bethesda, MD, 20892, (301) 519-3153, (888) 644-6226, (866) 464-3616, [email protected], http://nccam.nih.gov.

Rebecca J. Frey Ph.D.